The New England Journal of Medicine, the most prestigious and influential medical research publication in this country, enters its 200th year.  During that time, its staff and contributors have witnessed vast changes in medical knowledge and practice.  These include the acceptance of the germ theory of disease, the discovery of antibiotics, the use of hygiene in surgery, vaccination, discovery of the causes and effective treatments for heart disease, and the debunking of flawed therapies like bloodletting and forced sterilization.

It was not without concern that they also witnessed the inevitable move toward specialization that accompanied the expansion of knowledge.  The Journal commented in 1924: “Are we not losing sight of that fundamental thread of truth that gives us a perspective of the real value of our work; that enables us to consider our patient as an individual and not a pathological unit of a human body or a representative of an age group?”

In 1923 one physician complained, “How much can the specialist know of home conditions, of family difficulties, and their relation to the case?”

In the last 90 years things have likely gotten worse, as knowledge and technological advances have exploded.  The vast majority of physicians go into specialty training; reimbursement is higher, and many are heavily in debt by the time they finish medical school.  Editorials predict the demise of general practice and internal medicine.  Those fields are already encroached by nurse practitioners and physician assistants.

Care of the entire patient is not easy.  It requires a lot of training and experience, skill in communication and a willingness to promote coordination of care.  Important situations and diagnoses can be missed when someone is not involved who can look at the whole picture.  It is not sufficient for one specialist to refer to the next, then to the next.   Patients know that they are not a pair of lungs or a pancreas.  They need and should have a comprehensive, a holistic approach.

Allan Sosin MD

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